Organ preservation for rectal cancer

Effect of neoadjuvant therapy on textbook outcomes in minimally invasive rectal cancer surgery

AIM

Textbook outcome (TO), a combined quality indicator, encompasses key postoperative indicators such as the absence of complications, R0 resection, and no prolonged length of day. It has been suggested to be of additional value over single outcome parameters in short-term outcomes of surgical treatment. The main objective of this research was to assess the relationship between TO and neoadjuvant therapy (NT), thereby providing insights into NT's role in surgical quality.

METHOD

Patients who underwent minimally invasive rectal surgery were enrolled between January 2019 and June 2024. TO was defined as achieving R0 resection, at least 12 lymph nodes harvested, no adverse outcomes (Clavien-Dindo score ≥ 3, readmission, or mortality within 30 days), and length of stay within the ≤ 75th percentile for the treatment year. The relationship between TO and NT was analyzed using regression analyses. Subgroup analysis and hierarchical regression were conducted to investigate potential influencing factors and interactions.

RESULTS

405 patients were enrolled, with 204 achieving TO. NT was associated with a reduction in TO (OR: 0.37, 95% CI: 0.21 ~ 0.65, p < 0.001), while robotic surgery (OR: 2.88, 95% CI: 1.62 ~ 5.11), total laparoscopic surgery (OR: 2.79, 95% CI: 1.71 ~ 4.56), enhanced recovery after surgery (OR: 1.62, 95% CI: 1.02 ~ 2.59), and stoma (OR: 1.87, 95% CI: 1.18 ~ 2.96) were associated with an increased rate of TO. The impact of NT on TO varied depending on surgery duration; prolonged surgical time exacerbated the negative effect of NT on TO. This observation was consistent with a significant interaction effect.

CONCLUSION

NT is associated with a lower TO rate, especially in patients with prolonged surgical time. Robotic surgery, total laparoscopic surgery, enhanced recovery after surgery, and stoma can improve achieve TO.

Localized Rectal Cancer: Indian Consensus and Guidelines

The rising incidence of colorectal cancer (CRC) in India, particularly the prevalence of rectal cancer over colon cancer (0.7:1), has been a growing concern in recent decades; especially notable is the trend of increasing cases among young CRC patients. Given the diverse treatment approaches for rectal cancer globally and the varying economic capacities of patients in low to middle-income countries (LMICs) like India, it is essential to establish consensus guidelines that are specifically tailored to meet the needs of these patients. To achieve this, a panel comprising 30 eminent rectal cancer experts convened to conduct a comprehensive and impartial evaluation of existing practices and recent advancements in the field. Through meticulous scrutiny of published literature and a consensus-building process that involved voting on pertinent questions, the panel formulated management strategies. These recommendations are the result of a rigorous, evidence-based process and encapsulate the collective wisdom and judgment of leading authorities in the field.

Effect of laparoscopic versus open surgery on postoperative wound complications in patients with low rectal cancer: A meta-analysis

This meta-analysis was conducted to evaluate the effect of microinvasive and open operations on postoperative wound complications in low rectal carcinoma patients. Research on limited English has been conducted systematically in PubMed, Embase, Cochrane Library and Web of Science. The date up to the search was in August 2023. Following review of the classification and exclusion criteria for this research and the evaluation of its quality in the literature, there were a total of 266 related papers, which were reviewed for inclusion in the period from 2004 to 2017. A total of 1774 cases of low rectal cancer were enrolled. Of these 913 cases, the laparoscopic operation was performed on 913 cases, while 861 cases were operated on low rectal carcinoma. The overall sample was between 10 and 482. Five trials described the efficacy of laparoscopy have lower risk than open on postoperative wound infection in patients with low rectal cancer (OR, 0.72;95 % CI, 0.48,1.09 p = 0.12). Three studies results showed that the anastomotic leak was not significantly different between open and laparoscopy (OR, 0.86; 95% CI, 0.58,1.26 p = 0.44). Six surgical trials in low rectal cancer patients reported haemorrhage, and five cases of surgical time were reported, with laparoscopy having fewer bleeding compared with open surgery (MD, -188.89; 95% CI, -341.27, -36.51 p = 0.02). Compared with laparoscopy, the operation time was shorter for the open operation (MD, 33.06; 95% CI, 30.56, 35.57 p < 0.0001). Overall, there is no significant difference between laparoscopy and open surgery in terms of incidence of infection and anastomosis leak. However, the rate of haemorrhage in laparoscopy is lower，and operation time in open surgery is lower.

The Outcome of Local Excision of Rectal Adenomas with High-Grade Dysplasia by Transanal Endoscopic Microsurgery: A Single-Center Experience

Background: Local excision by transanal endoscopic microsurgery (TEM) is considered an acceptable treatment for rectal adenomas with high-grade dysplasia (HGD). This study aims to assess the likelihood of harboring an invasive carcinoma in preoperatively diagnosed HGD polyps and evaluate the risk factors for tumor recurrence in patients with final HGD pathology. Methods: Data from patients who underwent TEM procedures for adenomatous lesions with HGD from 2005 to 2018 at the Rabin Medical Center, Hasharon Hospital, were analyzed. Collected data included patient demographics, preoperative workup, tumor characteristics and postoperative results. Follow-up data including recurrence assessment and further treatments were reviewed. The analysis included two subsets: preoperative pathology of HGD (sub-group 1) and postoperative final pathology of HGD (sub-group 2) patients. Results: Forty-five patients were included in the study. Thirty-six patients had a preoperative diagnosis of HGD, with thirteen (36%) showing postoperative invasive carcinoma. Thirty-two patients had a final pathology of HGD, and three (9.4%) experienced tumor recurrence. Large tumor size (>5 cm) was significantly associated with recurrence (p = 0.03). Conclusions: HGD rectal polyps are associated with a significant risk of invasive cancer. Tumor size was a significant factor in predicting tumor recurrence in patients with postoperative HGD pathology. The TEM procedure is an effective first-line treatment for such lesions.

The benefits of adjuvant chemotherapy are associated with the kind of neoadjuvant therapy in stage ypI rectal cancer: evidence based on population analysis

PURPOSE

The oncological role of adjuvant chemotherapy (ACT) remains debated in locally advanced rectal cancer (RC) after neoadjuvant therapy (NAT), especially ypI RC. In this study, we used population-based data to evaluate the benefits of ACT in stage ypI RC after NAT and surgery. Moreover, we tried to differentiate what kind of NAT (radiotherapy alone or chemoradiotherapy) was administered because this may affect the further efficacy of ACT.

METHODS

All patients with stage ypI primary rectal malignancy were diagnosed in the SEER database between 2004 and 2017. The Kaplan-Meier method was applied to estimate the effects of ACT in survival analysis. Cox regression was performed to calculate the hazard ratio (HR) and the prognosis factors of survival. Propensity score matching (PSM) was used to balance the parameters between therapy groups.

RESULTS

The overall cohort's median follow-up time was 105 months. For 5-year OS and CSS, there were no significant differences between the ACT ( +) and ACT (-) groups (p = 0.105; p = 0.788). However, subgroup analyses according to the kind of NAT found that ACT improved overall survival (OS) and cancer-specific survival (CSS) in patients who received neoadjuvant radiotherapy (nRT) (p < 0.001, p = 0.015). Among patients who received neoadjuvant chemoradiotherapy (nCRT), no significant survival benefits were found between the ACT ( +) and ACT (-) groups (p = 0.526, p = 0.288).

CONCLUSION

Our population-based cohort study suggested that the efficacy of ACT was associated with the kind of NAT. The ACT provides survival benefits in stage ypI RC for patients who received nRT. However, among patients who received nCRT, ACT did not improve long-term survival.

Adjuvant chemotherapy does not improve cancer-specific survival for pathologic stage II/III rectal adenocarcinoma after neoadjuvant chemoradiotherapy and surgery: evidence based on long-term survival analysis from SEER data

PURPOSE

Adjuvant chemotherapy is controversial in rectal cancer, especially after neoadjuvant chemoradiotherapy (NCRT). This retrospective study aims at evaluating adjuvant chemotherapy's long-term survival benefits in stage II and stage III rectal adenocarcinoma (RC).

METHODS

This study obtained data from the Surveillance, Epidemiology, and End Results (SEER) database registered between 2010 and 2015. The survival analyses used the Kaplan-Meier method and were compared by log-rank test. The factors that affect survival outcomes were analyzed by univariate and multivariate Cox regression. The propensity score matching (1:4) was used to ensure the balance of variables between different groups.

RESULTS

The median follow-up time for overall patients was 64 months. The 5-year overall survival (OS) and cancer-specific survival (CSS) rates were 51.3% and 67.4% in the adjuvant chemotherapy (-) group and 73.9% and 79.6% in the adjuvant chemotherapy ( +) group (p < 0.001, p = 0.002). However, subgroup analysis showed adjuvant chemotherapy after NCRT improved the 5-year OS but not CSS rates in stage II and stage III RC (p = 0.003, p = 0.004; p = 0.29, p = 0.3). Univariate and multivariate analyses found adjuvant chemotherapy after NCRT was an independent prognosis factor of OS but not CSS (HR 0.8, 95%CI 0.7-0.92, p < 0.001; p = 0.276).

CONCLUSION

The survival benefits from adjuvant chemotherapy were associated with the status of NCRT for pathological stage II and III RC. For patients who did not receive NCRT, adjuvant chemotherapy is needed to significantly improve long-term survival rates. However, adjuvant chemotherapy after NCRT did not significantly improve long-term CSS.

Novel "resect and analysis" approach for T2 colorectal cancer with use of artificial intelligence

BACKGROUND AND AIMS

Because of a lack of reliable preoperative prediction of lymph node involvement in early-stage T2 colorectal cancer (CRC), surgical resection is the current standard treatment. This leads to overtreatment because only 25% of T2 CRC patients turn out to have lymph node metastasis (LNM). We assessed a novel artificial intelligence (AI) system to predict LNM in T2 CRC to ascertain patients who can be safely treated with less-invasive endoscopic resection such as endoscopic full-thickness resection and do not need surgery.

METHODS

We included 511 consecutive patients who had surgical resection with T2 CRC from 2001 to 2016; 411 patients (2001-2014) were used as a training set for the random forest-based AI prediction tool, and 100 patients (2014-2016) were used to validate the AI tool performance. The AI algorithm included 8 clinicopathologic variables (patient age and sex, tumor size and location, lymphatic invasion, vascular invasion, histologic differentiation, and serum carcinoembryonic antigen level) and predicted the likelihood of LNM by receiver-operating characteristics using area under the curve (AUC) estimates.

RESULTS

Rates of LNM in the training and validation datasets were 26% (106/411) and 28% (28/100), respectively. The AUC of the AI algorithm for the validation cohort was .93. With 96% sensitivity (95% confidence interval, 90%-99%), specificity was 88% (95% confidence interval, 80%-94%). In this case, 64% of patients could avoid surgery, whereas 1.6% of patients with LNM would lose a chance to receive surgery.

CONCLUSIONS

Our proposed AI prediction model has a potential to reduce unnecessary surgery for patients with T2 CRC with very little risk. (Clinical trial registration number: UMIN 000038257.).

Clinical assessment for non-reversal stoma and stoma re-creation after reversal surgery for rectal cancer patients after sphincter-saving operation

BACKGROUND

This study aimed to identify the risk factors for permanent stoma (PS) in patients who underwent sphincter-saving operations for rectal cancer.

METHODS

We retrospectively reviewed 597 consecutive patients with rectal cancer from January 2012 to December 2020 at Taipei Medical University Hospital. Univariate and multivariable analyses were used to analyze risk factors for PS.

RESULTS

After a mean follow-up of 47.3 months (range 7-114 months), 59 patients (15.1%) were alive with a PS, including 46 patients who did not undergo reversal surgery and 13 patients who underwent stoma re-creation after reversal surgery. The mean period between primary surgery and stoma reversal was 6.0 months. Multivariate analysis revealed that the risk factors for PS were local recurrence [odd ratio (OR), 25.58; 95% confidence interval (CI), 4.428-147.761; p < 0.001], perirectal abscess [OR, 154.34; 95% CI, 15.806 - >999; p < 0.001], anastomosis site stenosis [OR, 187.081; 95% CI, 22.193 - >999; p < 0.001], perineural invasion [OR, 4.782; 95% CI, 1.22-18.736; p = 0.025], and operation time (min) [OR, 1.008; 95% CI, 1.002-1.014; p = 0.01].

CONCLUSIONS

Local recurrence, perirectal abscess, anastomosis site stenosis, perineural invasion, and operation time were independent risk factors for PS. Therefore, before a patient undergoes surgery for rectal cancer, surgeons should consider the possibility of the need for a PS, and patients should be informed before the operation that closure of the temporary stoma may not always be possible.

Extraperitoneal colostomy after laparoscopic abdominoperineal resection using a cannula for tunnel creation through a trocar port

BACKGROUND

Extraperitoneal colostomy (EPC) after laparoscopic abdominoperineal resection (APR) remains a challenge for surgeons. This study aims to summarize our laparoscopic EPC method and assess its effects versus a transperitoneal colostomy (TPC) for patients with rectal tumors.

METHODS

A total of 133 patients with rectal cancer treated with laparoscopic APR between May 2009 and May 2020 were retrospectively reviewed. The clinical data, including demographics, comorbidities, tumor stage, colostomy duration, and complications were compared between the EPC group and the TPC group.

RESULTS

The EPC group included 83 patients whose extraperitoneal tunnels were created using a cannula through a trocar port, and the TPC group included 50 patients whose stomata were formed traditionally. There were no differences in colostomy time [(23.1 ± 6) min vs. (21.4 ± 4) min, P = 0.078], number of parastomal dermatitis patients (5 vs. 2, P = 0.916), or number of stomal stenoses (1 vs. 1, P = 0.715) between the EPC and TPC groups. No cases of parastomal hernia developed in the EPC group, whereas 4 patients were diagnosed with a parastomal hernia; the difference between the two groups was statistically significant (P = 0.036).

CONCLUSIONS

Laparoscopic EPC have a lower incidence of parastomal hernia than TPC. It is easy and inexpensive to create an extraperitoneal tunnel using a cannula through a trocar port.

NCCN Guidelines Insights: Rectal Cancer, Version 6.2020

The NCCN Guidelines for Rectal Cancer provide recommendations for the diagnosis, evaluation, treatment, and follow-up of patients with rectal cancer. These NCCN Guidelines Insights summarize the panel discussion behind recent important updates to the guidelines. These updates include clarifying the definition of rectum and differentiating the rectum from the sigmoid colon; the total neoadjuvant therapy approach for localized rectal cancer; and biomarker-targeted therapy for metastatic colorectal cancer, with a focus on new treatment options for patients with BRAF V600E- or HER2 amplification-positive disease.

Radiomics-Based Preoperative Prediction of Lymph Node Status Following Neoadjuvant Therapy in Locally Advanced Rectal Cancer

Background and Purpose: Lymph node status is a key factor for the recommendation of organ preservation for patients with locally advanced rectal cancer (LARC) following neoadjuvant therapy but generally confirmed post-operation. This study aimed to preoperatively predict the lymph node status following neoadjuvant therapy using multiparametric magnetic resonance imaging (MRI)-based radiomic signature.

Materials and Methods: A total of 391 patients with LARC who underwent neoadjuvant therapy and TME were included, of which 261 and 130 patients were allocated to the primary cohort and the validation cohort, respectively. The tumor area, as determined by preoperative MRI, underwent radiomics analysis to build a radiomic signature related to lymph node status. Two radiologists reassessed the lymph node status on MRI. The radiomic signature and restaging results were included in a multivariate analysis to build a combined model for predicting the lymph node status. Stratified analyses were performed to test the predictive ability of the combined model in patients with post-therapeutic MRI T1-2 or T3-4 tumors, respectively.

Results: The combined model was built in the primary cohort, and predicted lymph node metastasis (LNM+) with an area under the curve of 0.818 and a negative predictive value (NPV) of 93.7% were considered in the validation cohort. Stratified analyses indicated that the combined model could predict LNM+ with a NPV of 100 and 87.8% in the post-therapeutic MRI T1-2 and T3-4 subgroups, respectively.

Conclusion: This study reveals the potential of radiomics as a predictor of lymph node status for patients with LARC following neoadjuvant therapy, especially for those with post-therapeutic MRI T1-2 tumors.

MRI Evaluation of the Response of Rectal Cancer to Neoadjuvant Chemoradiation Therapy

MRI plays a critical role in the staging and restaging of rectal cancer. Although newly diagnosed early-stage rectal cancers may immediately be amenable to surgical resection, patients with advanced disease first undergo neoadjuvant therapy that consists of a combination of chemotherapy and radiation therapy. Evaluation of rectal cancer after neoadjuvant therapy is best performed with MRI, given its superior soft-tissue contrast and its ability to allow multiplanar imaging and functional evaluation. In this setting, MRI allows accurate evaluation of primary tumor staging, which is determined on the basis of the depth of invasion within and through the rectal wall and the involvement of adjacent organs. MRI can also be used to evaluate posttreatment morphologic components within the tumors, including fibrosis and mucinous changes that have been shown to correlate with the response to treatment. Additional features such as the circumferential resection margin and extramural vascular invasion-factors shown to affect prognosis and local recurrence-are also assessed before and after therapy. Functional assessment with diffusion-weighted MRI and perfusion MRI plays a role in predicting tumor aggressiveness and the likelihood of response to treatment, as well as the extent of residual tumor after therapy. Lymph node staging is also performed at MRI, with assessment of not only lymph node size but also the internal architecture and signal intensity characteristics. ^©RSNA, 2019 See discussion on this article by Wasnik and Al-Hawary .

Surveillance Intensity Comparison by Risk for T1NX Locally Excised Rectal Adenocarcinoma: a Cost-Effective Analysis

BACKGROUND

Controversy exists regarding the optimal surveillance strategy following local excision of T1NX rectal adenocarcinoma. This study aims to determine the cost-effectiveness of surveillance strategies for locally excised T1NX rectal adenocarcinoma based on histopathologic and local staging risk factors.

METHODS

A Markov model with 10-year follow-up was developed for cost-effectiveness analysis of high-, medium-, and low-intensity surveillance strategies after local excision of T1NX rectal adenocarcinoma. Literature review and expert consensus were utilized to populate state/transition probabilities and rewards. Based on this data, 87% of T1NX patients undergoing local excision were low risk. Healthcare utilization costs were based on Centers for Medicare and Medicaid Services data. The primary outcomes were costs in 2018 US dollars and effectiveness in life-years presented as net monetary benefit and incremental cost-effectiveness ratios. One-way sensitivity and probabilistic sensitivity analyses were performed.

RESULTS

Net monetary benefit for low-, medium-, and high-intensity surveillance strategies ($393,117.00, $397,978.80, and $397,290.00) shows medium-intensity surveillance to be optimal. One-way sensitivity analysis shows medium-intensity surveillance to be optimal when the cohort is 73-94% low risk. High-intensity surveillance is preferred when less than 73% of the cohort is low risk. Low-intensity surveillance is preferred when greater than 94% is low risk. Probabilistic sensitivity analysis of the base-case shows medium-intensity surveillance is the optimal strategy for 51.5% of the iterations performed.

CONCLUSIONS

Medium-intensity surveillance is the most cost-effective surveillance strategy for locally excised T1NX rectal adenocarcinoma in a clinically representative population model.

Executive Summary of the American Radium Society Appropriate Use Criteria for Local Excision in Rectal Cancer

The goal of treatment for early stage rectal cancer is to optimize oncologic outcome while minimizing effect of treatment on quality of life. The standard of care treatment for most early rectal cancers is radical surgery alone. Given the morbidity associated with radical surgery, local excision for early rectal cancers has been explored as an alternative approach associated with lower rates of morbidity. The American Radium Society Appropriate Use Criteria presented in this manuscript are evidence-based guidelines for the use of local excision in early stage rectal cancer that include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) used by a multidisciplinary expert panel to rate the appropriateness of imaging and treatment procedures. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. These guidelines are intended for the use of all practitioners and patients who desire information regarding the use of local excision in rectal cancer.

Trends in combined radio-chemotherapy for locally advanced rectal cancer: a survey among radiation oncology centers of Sicily region on behalf of AIRO

AIM

To conduct a survey among Sicilian centers of radiation oncology belonging to Associazione Italiana di Radioterapia ed Oncologia Clinica (AIRO), to record the different methods of integration of radio-chemotherapy both in neoadjuvant and adjuvant settings, to evaluate surgical procedures in relation to the sphincter preservation and to report the different toxicity profiles of the treatment strategies.

METHODS

A questionnaire was sent at the end of 2017 to all the radiation oncology centers of Sicily region in order to collect the data from individual centers and the treatment characteristics retrospectively over the previous 5 years, from 2012 to 2016. The required data were collected from 13 centers out of 17 which, in relation to the single catchment areas, correspond to approximately 85% of the Sicilian population. The requested data concerned the type of integrated treatment (neoadjuvant vs adjuvant vs radical), combination with chemotherapy (induction, concomitant, adjuvant), type of surgical intervention (sphincter-saving vs abdomino-perineal resection), disease stage, schedule and radiotherapy technique adopted, as well as toxicity detected over the treatment period.

RESULTS

A total of 784 pts (M/F: 509/275) were treated between 2012 and 2016, with a median age of 67 years (range 25-92). The majority of patients was treated in the neoadjuvant phase (62% of the total) compared to the adjuvant phase (31%) and to those treated radically (7%). Twenty-five percent of patients did not receive combination chemotherapy mainly for cardiovascular problems. Chemotherapy used concomitantly to radiotherapy was single-agent capecitabine (73% of patients) or 5-fluorouracil (27%). The use of chemotherapy alone before concomitant treatment is more common for patients treated in the adjuvant phase (64% of this subgroup), while 14% of patients treated in the neoadjuvant phase received induction chemotherapy before the concomitant phase; in both cases of chemotherapy alone, the majority of patients (91%) received oxaliplatin-based protocols (FOLFOX/XELOX/CAPOX). Few patients (3%) received chemotherapy alone after the concomitant phase. Information on the surgical treatment received is available for 88% of the sample. Of these, 93% received a surgical treatment. The overall rate of sphincter-saving surgery (anterior resection) was 72%, but the contribution of neoadjuvant treatment allowed to reach a rate of 83% in this subgroup (against 65% found in the subgroup of patients treated in adjuvant phase). Traditional radiotherapy schedule (45-50 Gy in 25-28 fractions) was used in 90% of patients, of which an intensified treatment in neoadjuvant phase (45 Gy + boost of 9-10 Gy) was used in 11% of patients. A short-course regimen (25 Gy in 5 fraction) in neoadjuvant setting was opted rarely (7%). Three-dimensional conformal technique was preferred over intensity-modulated ones (73% vs 27%). Toxicity was mainly of grade I-II CTCAE (skin 23%, gastrointestinal 39%, genitourinary 14%) compared to grade III (gastrointestinal 4%, genitourinary and hematological < 1%). Interestingly, the toxicity rates were significantly higher in the adjuvant group compared to the neoadjuvant (GI: 58% vs 31%, GU: 21% vs 10%).

CONCLUSION

The present survey shows that in the Sicily region integrated therapies for rectal cancer have allowed a neoadjuvant approach in the majority of patients, thus resulting in a greater use of sphincter conservative surgery. The toxicity has also been reported to be significantly less in this treatment setting.

Early colorectal cancer: diagnosis, treatment and survivorship care

CRC is the third most commonly diagnosed malignancy and the fourth leading cause of cancer-related death in the world. With advances in treatment, colorectal cancer is being transformed from a deadly disease to an illness that is increasingly curable. With this transformation has come increased interest in the unique problems, risks, needs, and concerns of survivors who have completed treatment and are cancer-free. They often suffer late/long-term side effects of therapies that may compromise their QoL such as fatigue, sleep difficulty, fear of recurrence, anxiety, depression, negative body image, sensory neuropathy, gastrointestinal problems, urinary incontinence, and sexual dysfunction. In this review, we discuss what is known about early colorectal diagnosis, staging, treatments and their long-term effects on quality of life and survivorship care.

The protective effects of melatonin on blood cell counts of rectal cancer patients following radio-chemotherapy: a randomized controlled trial

PURPOSE

We aimed to examine the radioprotective effects of melatonin on the blood cell counts of patients with rectum cancer undergoing radiotherapy.

MATERIALS AND METHODS

This double-blind placebo-controlled study was conducted on 60 rectal cancer patients who were referred to Rajaii Hospital of Babolsar, Iran. An equal number of patients were randomly assigned to the control group which received placebo and study group which received 20 mg melatonin a day as an intervention. The melatonin was administered 5 days a week for 28 days. Blood samples were taken before melatonin received on day 1 and also day 28; then, to measure the changes in blood cell counts representing our primary outcomes, the samples were analyzed by Sysmex K810i auto-analyzer.

RESULTS

Our results showed that the platelet, white blood cells, lymphocyte, and neutrophil population reduction induced by radiotherapy were slighter or even insignificant in melatonin recipients compared to control. However, the difference between red blood cells in both groups was not significant.

CONCLUSION

Our results are indicating that melatonin could prevent or minimize the unfavorable effects of radiotherapy on blood cell count reductions by attenuating the adverse influence of radiation, probably through stimulation of cellular antioxidant potential as previously reported in animal models.

IRANIAN REGISTRY OF CLINICAL TRIALS (IRCT)

Registry No. IRCT2016021626586N1.

Evolution of transanal total mesorectal excision for rectal cancer: From top to bottom

The gold standard for curative treatment of locally advanced rectal cancer involves radical resection with a total mesorectal excision (TME). TME is the most effective treatment strategy to reduce local recurrence and improve survival outcomes regardless of the surgical platform used. However, there are associated morbidities, functional consequences, and quality of life (QoL) issues associated with TME; these risks must be considered during the modern-day multidisciplinary treatment for rectal cancer. This has led to the development of new surgical techniques to improve patient, oncologic, and QoL outcomes. In this work, we review the evolution of TME to the transanal total mesorectal excision (TaTME) through more traditional minimally invasive platforms. The review the development, safety and feasibility, proposed benefits and risks of the procedure, implementation and education models, and future direction for research and implementation of the TaTME in colorectal surgery. While satisfactory short-term results have been reported, the procedure is in its infancy, and long term outcomes and definitive results from controlled trials are pending. As evidence for safety and feasibility accumulates, structured training programs to standardize teaching, training, and safe expansion will aid the safe spread of the TaTME.

Mechanical suture in rectal cancer

Background and aims

Colorectal cancer is one of the most frequent digestive malignancies, being the third cause of death by cancer, despite early diagnosis and therapeutic progress made over the past years. Standard treatment in these patients is to preserve the anal sphincter with restoration of intestinal function by mechanical colorectal anastomosis or coloanal anastomosis, and to maintain genitourinary function by preservation of hypogastric nerves.

Methods

In order to emphasize the importance of this surgical technique in the Fourth Surgical Clinic of the CF Clinical Hospital Cluj-Napoca, we conducted a prospective observational interventional study over a 3-year period (2013–2016) in 165 patients hospitalized for rectal and rectosigmoid adenocarcinoma in various disease stages, who underwent Dixon surgery using the two techniques of manual and mechanical end-to-end anastomosis. For mechanical anastomosis, we used Covidien and Panther circular staplers. The patients were assigned to two groups, group A in which Dixon surgery with manual end-to-end anastomosis was performed (116 patients), and group B in which Dixon surgery with mechanical end-to-end anastomosis was carried out (49 patients).

Results

Mechanical anastomosis allowed to restore intestinal continuity following low anterior resection in 21 patients with lower rectal adenocarcinoma compared to 2 patients in whom intestinal continuity was restored by manual anastomosis, with a statistically significant difference (p<0.000001). The double-row mechanical suture technique is associated with a reduced duration of surgery (121.67 minutes for Dixon surgery with mechanical anastomosis, compared to 165.931 minutes for Dixon surgery with manual anastomosis, p<0.0001).

Conclusion

The use of circular transanal staplers facilitates end-to-end anastomosis by double-row mechanical suture, allowing to perform low anterior resection in situations when the restoration of intestinal continuity by manual anastomosis is technically not possible, with the aim to preserve the anal sphincter, to restore intestinal function and maintain genitourinary function through preservation of hypogastric nerves.

Organ preservation for rectal cancer (GRECCAR 2): a prospective, randomised, open-label, multicentre, phase 3 trial

BACKGROUND

Organ preservation is a concept proposed for patients with rectal cancer after a good clinical response to neoadjuvant chemotherapy, to potentially avoid morbidity and side-effects of rectal excision. The objective of this study was to compare local excision and total mesorectal excision in patients with a good response after chemoradiotherapy for lower rectal cancer.

METHODS

We did a prospective, randomised, open-label, multicentre, phase 3 trial at 15 tertiary centres in France that were experts in the treatment of rectal cancer. Patients aged 18 years and older with stage T2T3 lower rectal carcinoma, of maximum size 4 cm, who had a good clinical response to neoadjuvant chemoradiotherapy (residual tumour ≤2 cm) were centrally randomly assigned by the surgeon before surgery to either local excision or total mesorectal excision surgery. Randomisation, which was done via the internet, was not stratified and used permuted blocks of size eight. In the local excision group, a completion total mesorectal excision was required if tumour stage was ypT2-3. The primary endpoint was a composite outcome of death, recurrence, morbidity, and side-effects at 2 years after surgery, to show superiority of local excision over total mesorectal excision in the modified intention-to-treat (ITT) population (expected proportions of patients having at least one event were 25% vs 60% for superiority). This trial was registered with ClinicalTrials.gov, number NCT00427375.

FINDINGS

From March 1, 2007, to Sept 24, 2012, 186 patients received chemoradiotherapy and were enrolled in the study. 148 good clinical responders were randomly assigned to treatment, three were excluded (because they had metastatic disease, tumour >8 cm from anal verge, and withdrew consent), and 145 were analysed: 74 in the local excision group and 71 in the total mesorectal excision group. In the local excision group, 26 patients had a completion total mesorectal excision. At 2 years in the modified ITT population, one or more events from the composite primary outcome occurred in 41 (56%) of 73 patients in the local excision group and 33 (48%) of 69 in the total mesorectal excision group (odds ratio 1·33, 95% CI 0·62-2·86; p=0·43). In the modified ITT analysis, there was no difference between the groups in all components of the composite outcome, and superiority was not shown for local excision over total mesorectal excision.

INTERPRETATION

We failed to show superiority of local excision over total mesorectal excision, because many patients in the local excision group received a completion total mesorectal excision that probably increased morbidity and side-effects, and compromised the potential advantages of local excision. Better patient selection to avoid unnecessary completion total mesorectal excision could improve the strategy.

FUNDING

National Cancer Institute of France, Sanofi, Roche Pharma.

Short-term and Long-term Outcomes Regarding Laparoscopic Versus Open Surgery for Low Rectal Cancer: A Systematic Review and Meta-Analysis

PURPOSE

It is to disclose whether the laparoscopic technique is feasible or not in the treatment of low rectal cancer.

MATERIALS AND METHODS

We systematically searched PubMed, Embase, Ovid, Web of Science, Science Direct, SpringerLink, EBSCO, and the Cochrane Library databases for the eligible studies. Review Manager 5.2 was used to test the heterogeneity and to evaluate the overall test performance.

RESULTS

Twelve studies met the final inclusion criteria (total n=2973). The pooled analyses showed, despite longer operation times, that there were significantly less blood loss, fewer transfusions, shorter times to bowel function recovery, resumed diet and hospital durations, and lower overall complication and wound infection rates. The compared results of the lymph node harvest number, distal resection margin, circumferential resection margin involvement, local and distant recurrences, disease-free survival, and overall survival were similar between both the groups.

CONCLUSION

Laparoscopic surgery is safe and feasible for the treatment of low rectal cancer.

Use of Preoperative MRI to Select Candidates for Local Excision of MRI-Staged T1 and T2 Rectal Cancer: Can MRI Select Patients With N0 Tumors?

BACKGROUND

To minimize the recurrence rate after local excision of rectal cancer, the false-negative rate of nodal staging should be minimized.

OBJECTIVE

The purpose of this study was to develop a set of criteria using preoperative MRI that would minimize the false-negative rate for the diagnosis of regional lymph node metastasis.

DESIGN

A prospectively maintained colorectal cancer database and MRI images were retrospectively reviewed.

SETTINGS

This study was conducted at a multidisciplinary tertiary center.

PATIENTS

A total of 246 consecutive patients who underwent MRI and curative-intent surgery for MRI-staged T1/T2 rectal cancer from January 2008 to July 2012 were included.

MAIN OUTCOME MEASURES

MRI features significantly associated with lymph node metastasis were identified using a χ test. Five diagnostic criteria for lymph node metastasis were created based on these predictive MRI features, and their false-negative rates were compared using the generalized estimating equation method.

RESULTS

Small size/homogeneity of lymph nodes and no visible tumor/partially involved muscular layer were significantly associated with lower risks of lymph node metastasis. When tumor invasion depth was not considered, the false-negative rate did not decrease below 10%, even when the strictest criterion for morphologic evaluation of lymph nodes (not visible or <3 mm) was used. Adding invasion depth to the diagnostic criteria significantly decreased the false-negative rate as low as 1.8%.

LIMITATIONS

This study is limited by its small sample size and retrospective nature.

CONCLUSIONS

Assessing both the depth of tumor invasion and lymph node morphology may reduce the false-negative rate and can be helpful to better identify candidates suitable for local excision of early stage rectal cancer. However, strict MRI criteria for oncologic safety might result in considerable false-positive cases and limit the application of local excision.

Modified simultaneous integrated boost radiotherapy for an unresectable huge refractory pelvic tumor diagnosed as a rectal adenocarcinoma

A clinical trial of radiotherapy with modified simultaneous integrated boost (SIB) technique against huge tumors was conducted. A 58-year-old male patient who had a huge pelvic tumor diagnosed as a rectal adenocarcinoma due to familial adenomatous polyposis was enrolled in this trial. The total dose of 77 Gy (equivalent dose in 2 Gy/fraction) and 64.5 Gy was delivered to the center of the tumor and the surrounding area respectively, and approximately 20% dose escalation was achieved with the modified SIB technique. The tumor with an initial maximum size of 15 cm disappeared 120 d after the start of the radiotherapy. Performance status of the patient improved from 4 to 0. Radiotherapy with modified SIB may be effective for patients with a huge tumor in terms of tumor shrinkage/disappearance, improvement of QOL, and prolongation of survival.

Simultaneous resection for rectal cancer with synchronous liver metastasis is a safe procedure

BACKGROUND

One quarter of colorectal cancer patients will present with liver metastasis at the time of diagnosis. Recent studies have shown that simultaneous resections are safe and feasible for stage IV colon cancer. Limited data are available for simultaneous surgery in stage IV rectal cancer patients.

METHODS

One hundred ninety-eight patients underwent surgical treatment for stage IV rectal cancer. In 145 (73%) patients, a simultaneous procedure was performed. Fifty-three (27%) patients underwent staged liver resection. A subpopulation of 69 (35%) patients underwent major liver resection (3 segments or more) and 30 (44%) patients with simultaneous surgery.

RESULTS

The demographics of the 2 groups were similar. Complication rates were comparable for simultaneous or staged resections, even in the group subjected to major liver resection. Total hospital stay was significantly shorter for the simultaneously resected patients (P < .01).

CONCLUSIONS

Simultaneous resection of rectal primaries and liver metastases is a safe procedure in carefully selected patients at high-volume institutions, even if major liver resections are required.

Optimal Time Intervals between Pre-Operative Radiotherapy or Chemoradiotherapy and Surgery in Rectal Cancer?

BACKGROUND

In rectal cancer therapy, radiotherapy or chemoradiotherapy (RT/CRT) is extensively used pre-operatively to (i) decrease local recurrence risks, (ii) allow radical surgery in non-resectable tumors, and (iii) increase the chances of sphincter-saving surgery or (iv) organ-preservation. There is a growing interest among clinicians and scientists to prolong the interval from the RT/CRT to surgery to achieve maximal tumor regression and to diminish complications during surgery.

METHODS

The pros and cons of delaying surgery depending upon the aim of the pre-operative RT/CRT are critically evaluated.

RESULTS

Depending upon the clinical situation, the need for a time interval prior to surgery to allow tumor regression varies. In the first and most common situation (i), no regression is needed and any delay beyond what is needed for the acute radiation reaction in surrounding tissues to wash out can potentially only be deleterious. After short-course RT (5Gyx5) with immediate surgery, the ideal time between the last radiation fraction is 2-5 days, since a slightly longer interval appears to increase surgical complications. A delay beyond 4 weeks appears safe; it results in tumor regression including pathologic complete responses, but is not yet fully evaluated concerning oncologic outcome. Surgical complications do not appear to be influenced by the CRT-surgery interval within reasonable limits (about 4-12 weeks), but this has not been sufficiently explored. Maximum tumor regression may not be seen in rectal adenocarcinomas until after several months; thus, a longer than usual delay may be of benefit in well responding tumors if limited or no surgery is planned, as in (iii) or (iv), otherwise not.

CONCLUSION

A longer time interval after CRT is undoubtedly of benefit in some clinical situations but may be counterproductive in most situations. After short-course RT, long-term results from the clinical trials are not yet available to routinely recommend an interval longer than 2-5 days, unless the tumor is non-resectable at diagnosis.

Neo-adjuvant radiotherapy in rectal cancer

In rectal cancer treatment, attention has focused on the local primary tumour and the regional tumour cell deposits to diminish the risk of a loco-regional recurrence. Several large randomized trials have also shown that combinations of surgery, radiotherapy and chemotherapy have markedly reduced the risk of a loco-regional recurrence, but this has not yet had any major influence on overall survival. The best results have been achieved when the radiotherapy has been given preoperatively. Preoperative radiotherapy improves loco-regional control even when surgery has been optimized to improve lateral clearance, i.e., when a total mesorectal excision has been performed. The relative reduction is then 50%-70%. The value of radiotherapy has not been tested in combination with more extensive surgery including lateral lymph node clearance, as practised in some Asian countries. Many details about how the radiotherapy is performed are still open for discussion, and practice varies between countries. A highly fractionated radiation schedule (5 Gy × 5), proven efficacious in many trials, has gained much popularity in some countries, whereas a conventionally fractionated regimen (1.8-2.0 Gy × 25-28), often combined with chemotherapy, is used in other countries. The additional therapy adds morbidity to the morbidity that surgery causes, and should therefore be administered only when the risk of loco-regional recurrence is sufficiently high. The best integration of the weakest modality, to date the drugs (conventional cytotoxics and biologicals) is not known. A new generation of trials exploring the best sequence of treatments is required. Furthermore, there is a great need to develop predictors of response, so that treatment can be further individualized and not solely based upon clinical factors and anatomic imaging.

When is local excision appropriate for "early" rectal cancer?

Local excision is increasingly performed for “early stage” rectal cancer in the US; however, local recurrence after local excision has become a controversial issue in Western countries. Local recurrence is considered to originate based on the type of tumor and procedure performed, and in surgical margin-positive cases. This review focuses on the inclusion criteria of “early” rectal cancers for local excision from the Western and Japanese points of view. “Early” rectal cancer is defined as T1 cancer in the rectum. Only the tumor grade and depth of invasion are the “high risk” factors which can be evaluated before treatment. T1 cancers with sm1 or submucosal invasion <1,000 μm are considered to be “low risk” tumors with less than 3.2 % nodal involvement, and are considered to be candidates for local excision as the sole curative surgery. Tumors with a poor tumor grade should be excluded from local excision. Digital examination, endoscopy or proctoscopy with biopsy, a barium enema study and endorectal ultrasonography are useful for identifying “low risk” or excluding “high risk” factors preoperatively for a comprehensive diagnosis. The selection of an initial local treatment modality is also considered to be important according to the analysis of the nodal involvement rate after initial local treatment and after radical surgery.

Efficacy and safety of preoperative radiochemotherapy combined with total mesorectal excision in treatment of stage Ⅱ/Ⅲ rectal cancer

AIM: To assess the efficacy and safety of preoperative radiochemotherapy combined with total mesorectal excision (TME) in the treatment of stage Ⅱ/Ⅲ rectal cancer.

METHODS: One hundred and twelve patients with stage Ⅱ/Ⅲ rectal cancer, who were hospitalized in Department of Gastrointestinal Surgery of the First Affiliated Hospital of Zhengzhou University from January 2006 to December 2011 were collected and equally divided into two groups to receive either preoperative radiochemotherapy combined with TME (group A) or TME alone (group B). The R0 resection rate, anal preservation rate, local recurrence rate and long-term survival rate were compared between the two groups.

RESULTS: There were significant differences in R0 radical resection rate (91.1% vs 75%, P < 0.05) and anal preservation rate (64.7% vs 26.3%, P < 0.05) between the two groups, although no significant difference was observed in the rates of anastomotic leakage (6.0% vs 4.8%, P > 0.05) and poor healing of incision (12.5% vs 8.9%, P > 0.05). The 3-year local recurrence rate was significantly lower in group A than in group B (8.9% vs 26.8%, P < 0.05), but there were no significant differences in the 3-year survival rate (80.4% vs 71.4%, P > 0.05) or 5-year survival rate (57.1% vs 53.6%, P > 0.05) between the two groups.

CONCLUSION: Preoperative chemoradiotherapy can increase the rates of R0 radical resection and anal preservation but can not increase the rate of complications. Preoperative chemoradiotherapy combined with TME can significantly reduce the 3-year local recurrence rate but can not improve the long-term survival rate.

Rectal cancer staging: focus on the prognostic significance of the findings described by high-resolution magnetic resonance imaging

High-resolution (HR) magnetic resonance imaging (MRI) has become an indispensable tool for multidisciplinary teams (MDTs) addressing rectal cancer. It provides anatomic information for surgical planning and allows patients to be stratified into different groups according to the risk of local and distant recurrence. One of the objectives of the MDT is the preoperative identification of high-risk patients who will benefit from neoadjuvant treatment. For this reason, the correct evaluation of the circumferential resection margin (CRM), the depth of tumor spread beyond the muscularis propria, extramural vascular invasion and nodal status is of the utmost importance. Low rectal tumors represent a special challenge for the MDT, because decisions seek a balance between oncologic safety, in the pursuit of free resection margins, and the patient's quality of life, in order to preserve sphincter function. At present, the exchange of information between the different specialties involved in dealing with patients with rectal cancer can rank the contribution of colleagues, auditing their work and incorporating knowledge that will lead to a better understanding of the pathology. Thus, beyond the anatomic description of the images, the radiologist's role in the MDT makes it necessary to know the prognostic value of the findings that we describe, in terms of recurrence and survival, because these findings affect decision making and, therefore, the patients' life. In this review, the usefulness of HR MRI in the initial staging of rectal cancer and in the evaluation of neoadjuvant treatment, with a focus on the prognostic value of the findings, is described as well as the contribution of HR MRI in assessing patients with suspected or confirmed recurrence of rectal cancer.

Selecting patients with locally advanced rectal cancer for neoadjuvant treatment strategies

Rectal cancer remains a significant problem worldwide. Outcomes vary significantly according to the stage of disease and prognostic factors, including the distance of the tumor from the circumferential resection margin. Accurate staging, including high-resolution magnetic resonance imaging, allows stratification of patients into low-, moderate-, and high-risk disease; this information can be used to inform multidisciplinary team decisions regarding the role of neoadjuvant therapy. Both neoadjuvant short-course radiotherapy and long-course chemoradiation reduce the risk of local recurrence compared with surgery alone, but they have little impact on survival. Although there remains a need to reduce overtreatment of those patients at moderate risk, evaluation of intensified regimens for those with high-risk disease is still required to reduce distant failure rates and improve survival in these patients with an otherwise poor prognosis.

The management of patients with T1 adenocarcinoma of the low rectum: a decision analysis

BACKGROUND

Decision making for patients with T1 adenocarcinoma of the low rectum, when treatment options are limited to a transanal local excision or abdominoperineal resection, is challenging.

OBJECTIVES

The aim of this study was to develop a contemporary decision analysis to assist patients and clinicians in balancing the goals of maximizing life expectancy and quality of life in this situation.

DESIGN

We constructed a Markov-type microsimulation in open-source software. Recurrence rates and quality-of-life parameters were elicited by systematic literature reviews. Sensitivity analyses were performed on key model parameters.

PATIENTS AND SETTING

Our base case for analysis was a 65-year-old man with low-lying T1N0 rectal cancer. We determined the sensitivity of our model for sex, age up to 80, and T stage.

MAIN OUTCOME MEASURES

The main outcome measured was quality-adjusted life-years.

RESULTS

In the base case, selecting transanal local excision over abdominoperineal resection resulted in a loss of 0.53 years of life expectancy but a gain of 0.97 quality-adjusted life-years. One-way sensitivity analysis demonstrated a health state utility value threshold for permanent colostomy of 0.93. This value ranged from 0.88 to 1.0 based on tumor recurrence risk. There were no other model sensitivities.

LIMITATIONS

Some model parameter estimates were based on weak data.

CONCLUSIONS

In our model, transanal local excision was found to be the preferable approach for most patients. An abdominoperineal resection has a 3.5% longer life expectancy, but this advantage is lost when the quality-of-life reduction reported by stoma patients is weighed in. The minority group in whom abdominoperineal resection is preferred are those who are unwilling to sacrifice 7% of their life expectancy to avoid a permanent stoma. This is estimated to be approximately 25% of all patients. The threshold increases to 12% of life expectancy in high-risk tumors. No other factors are found to be relevant to the decision.

Patterns of Practice in the Radiation Therapy Management of Rectal Cancer: Survey of the Interregional Group Piedmont, Valle d'Aosta and Liguria of the “Associazione Italiana di Radioterapia Oncologica (AIRO)”

Aims and background

To report the survey about the main aspects on the use of radiotherapy for the treatment of rectal cancer in Piedmont and Liguria.

Methods and study design

Sixteen centers (11 from Piedmont and 5 from Liguria) received and answered by email a questionnaire data base about clinical and technical aspects of the treatment of rectal cancer. All data were incorporated in a single data base and analyzed.

Results

Data regarding 593 patients who received radiotherapy for rectal cancer during the year 2009 were collected and analyzed. Staging consisted in colonoscopy, thoracic and abdominal CT, pelvic MRI and endoscopic ultrasound. PET/CT was employed to complete staging and in the treatment planning in 12/16 centers (75%). Neoadjuvant radiotherapy was employed more frequently than adjuvant radiotherapy (50% vs 36.4%), using typically a total dose of 45 Gy with 1.8 Gy/fraction. Concurrent chemoradiation with 5-fluorouracil or capecitabine was mainly employed in neoadjuvant and adjuvant settings, whereas oxaliplatin alone or in combination with 5-FU or capecitabine and leucovorin was commonly employed as the adjuvant agent. The median interval from neoadjuvant treatment to surgery was 7 weeks after long-course radiotherapy and 8 days after short-course radiotherapy. The pelvic total dose of 45 Gy in the adjuvant setting was the same in all the centers. Doses higher than 45 Gy were employed with a radical intent or in case of positive surgical margins. Hypofractionated regimens (2.5, 3 Gy to a total dose of 35–30 Gy) were used in the palliative setting. No relevant differences were observed in target volume definition and patient setup. Twenty-six patients (4.4%) developed grade 3 acute toxicity. Follow-up was scheduled in a similar way in all the centers.

Conclusions

No relevant differences were found among the centers involved in the survey. The approach can help clinicians to address important clinical questions and to improve consistency and homogeneity of treatments.

Toward the non-surgical management of locally advanced rectal cancer

Neoadjuvant short-course radiotherapy and long-course chemoradiation (CRT) reduce local recurrence rates when compared to surgery alone and remain widely accepted as standard of care for patients with locally advanced rectal cancer. However, surgery is not without complications and a non-surgical approach in carefully selected patients warrants evaluation. A pathological complete response to CRT is associated with a significant improvement in survival and it has been suggested that a longer time interval between the completion of CRT and surgery increases tumor downstaging. Intensification of neoadjuvant treatment regimens to increase tumor downstaging has been evaluated in a number of clinical trials and more recently the introduction of neoadjuvant chemotherapy prior to CRT has demonstrated high rates of radiological tumor regression. Careful selection of patients using high-resolution MRI may allow a non-surgical approach in a subgroup of patients achieving a complete response to neoadjuvant therapies after an adequate time period. Clearly this needs prospective evaluation within a clinical trial setting, incorporating modern imaging techniques, and tissue biomarkers to allow accurate prediction and assessment of response.

Multidisciplinary treatment of patients with rectal cancer: Development during the past decades and plans for the future

In rectal cancer treatment, both the local primary and the regional and systemic tumour cell deposits must be taken care of in order to improve survival. The three main treatments, surgery, radiotherapy, and chemotherapy, each with their own advantages and limitations, must then be combined to improve results. Several large randomized trials have shown that combinations of the modalities have markedly reduced the loco-regional recurrences, but have not yet had any major influence on overall survival. The best integration of the weakest modality, to date the drugs (conventional cytotoxics and biologicals), is not known. A new generation of trials exploring the best sequence of treatments is required. Furthermore, treatment of rectal cancer is administered to populations of individuals, based upon clinical factors and imaging, and can presently not be further individualized. There is an urgent need to develop response predictors.

Recommendations and expert opinion on the treatment of locally advanced rectal cancer in Spain

In Spain 22,000 new cases of colorectal cancer are diagnosed each year, with 13,075 deaths resulting from this disease. Around 70% of colorectal cancers are localised in the colon and 30% in the rectum. A group of Spanish experts established recommendations on what would be the best strategy in the treatment of locally advanced rectal cancer (LARC). Adequate assessment of local tumour extension, including high-resolution magnetic resonance imaging and endorectal ultrasound, is essential for successful treatment. The three cornerstones in the treatment of LARC are surgery, radiotherapy and chemotherapy. Most patients will need a total mesorectal excision (TME). Preoperative chemo-radiotherapy (CRT) is preferred for the majority of patients with T3/T4 disease and/or regional node involvement, and adjuvant chemotherapy is recommended after a patient-sharing decision. Capecitabine, after showing a trend in improved downstaging in neoadjuvant stratum and the convenience of its oral administration, represents an alternative to 5-FU as perioperative treatment of LARC.

Can mesorectal lymph node excision be avoided in rectal cancer surgery?

Rectal excision is the standard in rectal cancer treatment. The morbidity of rectal excision, together with the low rate of positive lymph nodes in patients with a good response after radiochemotherapy, raises the challenging concept of organ preservation. Patients with a complete response can benefit from a nonoperative strategy based on a strict follow up. Those with a complete or subcomplete response can be treated by local excision. Limitations in accurately assessing a complete response by conventional and modern imaging modalities suggest that local excision is more appropriate for the majority of patients when organ preservation is being considered. The encouraging results of retrospective series of local excision in downstaged clinical T2/T3 low rectal cancer after radiochemotherapy, however, need to be confirmed by the ongoing multicentre phase II United States and phase III French trials before routinely proposing organ preservation in patients with a good response.

Preoperative intensified radiochemotherapy for rectal cancer: experience of a single institution

PURPOSE

The aim of our study was to evaluate the feasibility and the effectiveness of an intensified neoadjuvant protocol with the addition of weekly oxaliplatin in the preoperative strategy of rectal cancer treatment.

PATIENTS AND METHODS

Patients with locally advanced rectal cancer received continous infusion 5-Fluorouracil (5-FU) 200 mg/m(2)/day in combination with weekly oxaliplatin at a dose of 50 mg/m(2). Doses of radiotherapy were 45 Gy to the whole pelvis plus 5.4-9 Gy to the tumour mass. The primary end-points of the study were evaluation of toxicity, compliance with radiotherapy and chemotherapy, downstaging, pathological complete response (pCR) and the rate of sphincter preservation for distal cancers. Secondary end-points were relapse-free and overall survival.

RESULTS

From November 2006 to June 2009, 51 patients were enrolled into the study. Compliance with chemotherapy was 80%. The incidence of G3 diarrhoea and proctitis were 17.6% and 21.5%, respectively. Surgery was performed in 48 patients with 100% R0 resection. 76.4% of low-lying tumours underwent conservative treatment. Seventy-nine percent of patients were downstaged: T and N downstaging were observed in 71% and 75% of patients, respectively. A pCR was obtained in 11 (22.9%) patients.

CONCLUSIONS

Intensification of neoadjuvant treatment for rectal cancer with the addition of weekly oxaliplatin is feasible, with remarkable rates of downstaging and pathological complete response. Data on sphincter preservation for distal cancers were excellent. Phase III trials with a longer follow-up will establish whether this good outcome in terms of surrogate end-points will translate into better rates of disease-free and overall survival.

Oncological outcome of T1 rectal cancer undergoing standard resection and local excision

AIM

We studied the outcome and prognostic factors for T1 rectal cancer patients undergoing standard resection or transanal excision.

METHOD

One hundred and twenty-four patients with T1 rectal cancer were included in the study, of whom 66 (53.2%) underwent standard resection and 58 (46.8%) underwent transanal excision. Survival analysis was performed to compare the outcome.

RESULTS

The 5-year local recurrence rate was 11.0% in the transanal excision group versus 1.6% in the standard resection group (P = 0.031) but the 5-year disease-free survival and overall survival rates were not significantly different between the two groups. Multivariate analysis suggested that a high tumour grade and perineural or lymphovascular invasion were independent risk factors for local recurrence and recurrence-free survival. For high-risk patients (with at least one of the above risk factors), the 5-year local recurrence and 10-year recurrence-free survival rates were 21.2% and 74.5%, versus 1.2% and 92.0% in low-risk patients (P = 0.00003 and P = 0.003). In patients undergoing transanal excision, none in the low-risk group had local recurrence during follow up, while 40% (6 of 15) of patients in the high-risk group developed local recurrence within 5 years after surgery. The 5-year local recurrence rate was 45.0%.

CONCLUSION

Transanal excision in T1 rectal cancer may result in a high rate of local failure for patients with a high-grade tumour, or perineural or lymphovascular invasion. Local excision should be avoided as a curative treatment in high-risk patients.

Risk factors of nodal involvement in T2 colorectal cancer

PURPOSE

Because of the adverse consequences of radical resection of T2 colorectal cancer, criteria are needed for selection of patients who can safely undergo local excision without requiring additional radical surgery. We therefore conducted a retrospective study of patients with T2 colorectal cancer to identify risk factors for nodal involvement that might be used in selecting patients for local excision.

METHODS

We reviewed records from consecutive patients who had undergone curative resection of T2 colorectal cancer at the Department of Surgery, National Defense Medical College, Saitama, Japan, between 1985 and 2005. Data on conventional clinicopathologic variables were retrieved from pathology reports at the time of surgery, and archived slides were evaluated regarding potential risk factors such as extent of poorly differentiated component (grade I-III), myxoid cancer stroma, tumor budding, and growth pattern and invasion depth in the muscularis propria.

RESULTS

A total of 244 patients (139 men and 105 women) treated for T2 colorectal cancer were included. Nodal involvement was found in 7 (8.4%) of 83 patients classified as grade I on the poorly differentiated component vs. 47 (29.2%) of 161 patients classified as grade II or III (P < .001). Of 148 patients negative for myxoid cancer stroma, 30 (16.9%) had nodal involvement vs. 24 (36.4%) of 42 patients who were positive for myxoid cancer stroma (P = .0011). According to multiple variable logistic analysis, significant independent risk factors for nodal involvement included poorly differentiated component (P = .002), myxoid cancer stroma (P = .032), and lymphovascular invasion (P = .022).

CONCLUSIONS

Poorly differentiated component, myxoid cancer stroma, and lymphovascular invasion are significant independent risk factors for nodal involvement in T2 colorectal cancer. We need further study to validate these results on another data set, especially in patients with rectal cancer, and to confirm whether local resection of T2 rectal cancer is able to predict the nodal involvement before laparotomy.

[Site of local surgery in adenocarcinoma of the rectum T2N0M0]

INTRODUCTION

The local exeresis adenocarcinoma of the rectum T(2)N(0)M(0) (ADC-T2), using transanal endoscopic microsurgery (TEM), has the benefit of achieving lower morbidity with a better quality of life. However, local occurrence of the local exeresis is greater than 20%, which is unacceptable these days.

PATIENTS AND METHODS

Prospective, observational follow up study. The tumours committee agreed that those ADC-T2 patients could have the following treatments: total mesorectal excision (TME), simple TEM, TEM with postoperative chemo- and radiotherapy (Ct-Rt), preoperative Ct-Rt with subsequent TEM and radical surgical rescue (TME) within at least 4 weeks.

RESULTS

Of the 146 patients operated on using TEM, 75 had adenocarcinomas, 59 adenomas, 6 scarring wounds, 5 carcinoids and 1 GIST. Of the adenocarcinomas 22 were ADC-T2. Follow up: median of 16 months (range, 3-32 months). The overall local recurrence was 18% (4/22). According to the treatment strategy the local occurrence was: TEM as the only procedure, 20% (2/10). Radical surgical rescue was performed on 3 patients after TEM, with no local or systemic recurrences. TEM with Qt-Rt after surgery was performed on 6 patients, with a local recurrence of 33% (2/6). Ct-Rt and subsequent TEM in 3 patients, with no local or systemic recurrences.

CONCLUSIONS

Treatment of ADC-T2 using simple TEM is not effective. The combination of Ct-Rt after TEM, does not improve the results of TME. It is possible to rescue those patients without changing the overall survival. Preoperative Ct-Rt and TEM appears to be the approach that obtains a clinical and histological response, although a response is needed by clinical trials.